How do Smokers in a Snus-Prevalent Society Consider E-cigarettes, Snus, and Nicotine Replacement Therapy Products as Relevant Replacements for Cigarettes in the Event They Should Stop Smoking?

INTRODUCTION: Around 50 percent of the tobacco in Norway is consumed in the form of snus, a smokeless oral tobacco. We examined Norwegian smokers' openness, and thereby the potential reach, to use e-cigarettes, nicotine replacement therapy products (NRT), and snus in the event of quitting smoking, in a society where snus use is common. METHODS: Using data from an online survey of 4073 smokers from 2019 to 2021, we calculated predicted probabilities of smokers' being open, undecided, and not open to use e-cigarettes, snus, and NRT in the event they should quit smoking. RESULTS: Among daily smokers, the probability of being open to use e-cigarettes in the event of quitting smoking was .32. The corresponding probabilities for using snus and NRT were .22 and .19. Snus was the product with the highest probability of not being open (.60). NRT had the highest probability of being undecided (.39). Among smokers who had never used e-cigarettes or snus, the probabilities of being open were .13 for e-cigarettes, .02 for snus and .11 for NRT. CONCLUSIONS: In a snus-friendly norm climate where smokers have traditionally used snus as an alternative to cigarettes, the probability of using e-cigarettes in the event of smoking cessation was higher compared to both snus and NRT. However, among smokers who had never used e-cigarettes or snus, the likelihood of being open to use of NRT was similar to e-cigarettes, and higher than snus, which suggests that NRT may still play a role in smoking cessation. IMPLICATIONS: In a snus-prevalent country in the endgame phase of the cigarette epidemic, where robust infrastructure for tobacco control in combination with the availability of snus has reduced smoking to a minimum, the remaining smokers seem to prefer e-cigarettes to snus if they should quit smoking. This indicates that availability of several nicotine alternatives might increase the likelihood of a future product replacement within the small group of remaining smokers.

Nicotine Content in Swedish-Type Snus Sold in Norway From 2005 to 2020.

INTRODUCTION: Use of snus (moist smokeless tobacco) is widespread in Scandinavia and increasingly popular in the U.S. Snus products vary in terms of product design, portion size, and nicotine content. The aim of this study was to examine variations in the nicotine content in snus sold on the Norwegian market from 2005 to 2020. METHODS: We calculated the nicotine content in dry snus in milligram per gram (mg/g) and milligram per serving (mg/s), weighted by the products' market share from data on nicotine content, water content, and portion size (both for portion and loose snus) for the ten most sold snus products from each of the three largest manufacturers in 2005, 2010, 2015, and 2020. RESULTS: In all snus products combined, the nicotine content per gram snus (mg/g) increased from 16.3 to 24.1, while nicotine per serving (mg/s) was stable around 13.0. In portion snus, the nicotine content increased for both mg/g and mg/s, most notably from 2005 to 2010. In loose snus, mg/g decreased marginally, while mg/s was stable throughout the period. CONCLUSIONS: In a period with increasing snus use, the nicotine content in snus increased per gram snus, but not per serving. The stability in nicotine per serving is likely due to a decreasing market share of loose snus which accounted for 54% of the snus products in 2005 and 5% in 2020, and which traditionally has a high content of nicotine per serving. IMPLICATIONS: Use of snus is popular in Scandinavia, most notably in Sweden and Norway, but also increasingly common in Finland, especially among young adults. There are no prior market-based studies of variations in the nicotine content in Swedish snus over time. We found that the average amount of nicotine per gram snus sold on the Norwegian market increased in the period 2005 to 2020, most notably from 2005 to 2010, while the amount of nicotine per serving was stable in the same period, primarily due to a decreasing share of loose snus.

The Short-term Impact of Standardised Packaging on Smoking and Snus Use in Norway.

INTRODUCTION: Standardised packaging on tobacco products was required in Norway July 1, 2018. We report pre-registered analyses of the potential impact on daily smoking and on daily snus use among women and men. METHODS: Interrupted time series (segmented regression) on repeated cross-sectional surveys (2012-2019) from two sources: probability samples (Registry Sample, N = 46,957) and market research samples (Market Research Sample, N = 64,465) of Norwegian adults aged 16-79. Self-reported daily smoking and snus use were regressed on a step change impact variable, controlled for trend and demographics (sex, age, region, and education based on national registers in the Registry Sample, and self-reported in the Market Research Sample). RESULTS: There were tendencies of a decline in smoking (Odds Ratio [OR] = 0.94; 95% confidence interval [CI] = 0.87, 1.02; lower-tail p-value [Plower] = 0.07), and women's snus use (OR = 0.89; CI = 0.77, 1.03; Plower = 0.06), but not men's snus use (OR = 1.01; CI = 0.92, 1.11; Plower = 0.59). Analyses using only the Registry Sample did not detect declines in smoking (OR = 0.99; CI = 0.88, 1.11; Plower = 0.43) or women's snus use (OR = 0.99; CI = 0.80, 1.24]; Plower = 0.48), and indicated no decline in men's snus use (OR = 1.18; CI = 1.03, 1.35; Plower = 0.99). Exploratory analyses suggested potential acceleration of the declining trend in smoking (change in trends, OR = 0.97) and of the increasing trend in men's snus use (OR = 1.03). CONCLUSIONS: The analyses indicate that standardised packaging in Norway did not produce a decline in men's snus use. Results are inconclusive regarding smoking and women's snus use. Exploratory analyses indicated a decrease in smoking and an increase in men's snus use. IMPLICATIONS: We could not confirm or disconfirm whether standardised packaging is an effective tobacco control measure in a Norwegian context. According to our analyses, standardized packaging may have effects on smoking prevalence and women's snus use, but is unlikely to reduce men's snus use. The present results may reflect higher effectiveness of standardised packaging for products with stronger health warnings. As the results varied according to samples and outcomes, the study underlines the importance of pre-registering future analyses on this topic. Future confirmatory research should test models of gradual impact of standardised packaging.

Adolescents' Use of Nicotine-Free and Nicotine E-Cigarettes: A Longitudinal Study of Vaping Transitions and Vaper Characteristics.

INTRODUCTION: Although adolescents' nicotine addiction from e-cigarettes is a concern, few studies differentiate between vaping with and without nicotine. This study examines the prevalence of nicotine and nicotine-free vaping, maps transitions between vaping behaviors, and assesses differences in the personal characteristics of vapers in a sample of Norwegian adolescents. AIMS AND METHODS: Data came from a nationwide longitudinal study of adolescents (n = 2018) conducted in 2017 (T1), 2018 (T2), and 2019 (T3) (mean age: 14.2, 15.0, and 16.2). Using an online questionnaire, we measured vaping with and without nicotine, snus use, smoking, sensation-seeking, conduct problems, and levels of depression. RESULTS: Past 12-month vaping prevalence was stable (12%, 13%, and 15%). Among adolescents reporting vaping at T1, 66% had used e-cigarettes without nicotine, 22% with nicotine, and 12% were unsure of nicotine content. Individual vaping trajectories were unstable: of nicotine-free vapers, 54% became non-users, while 14% became nicotine vapers from T1 to T2. From T2 to T3, 50% became non-users, while 17% became nicotine vapers. Of nicotine vapers, 39% became non-users from T1 to T2, while 46% became non-users from T2 to T3. Compared to nicotine-free vapers, nicotine vapers had more conduct problems (mean = 3.67 vs 2.17), had more symptoms of depression (mean = 11.38 vs 6.95), and comprised more past 30-day snus users (33% vs 14%) and cigarette users (33% vs 9%). CONCLUSIONS: Adolescent vapers most commonly used e-cigarettes without nicotine, few of these transitioned into nicotine vaping, and a majority became non-users. Nicotine vapers were more likely to use other tobacco products and have more conduct problems and symptoms of depression compared to nicotine-free vapers. IMPLICATIONS: Reporting the prevalence of nicotine-free vaping is critical for assessing nicotine exposure and subsequent risks of nicotine addiction. This multi-cohort longitudinal study showed that use of nicotine-free e-cigarettes is common among young vapers in Norway. Adolescents' vaping patterns-both with and without nicotine-are generally temporal and experimental. Despite the majority of nicotine vapers becoming non-users, they are characterized by having more conduct problems and poorer mental health, and they more often used other tobacco products.

The greater use of flavoured snus among ever-smokers versus never-smokers in Norway.

BACKGROUND: Similar to the debate around e-cigarettes, an increase in snus use among Norwegian adolescents has prompted debate on whether flavour options in snus should be limited. To this end, we compared use of flavoured snus among snus users with different smoking status. METHODS: Questions about flavoured snus use were included in an online omnibus study conducted from 2015 to 2019 (N = 65,445) that included 16,295 ever snus users (aged 15+). Current snus users (N = 9783) were asked "Do you usually use snus that has a flavouring (liquorice, mint, wintergreen, etc.)? Adjusted predicted probabilities and 95% confidence intervals (CI) were calculated from a logistic regression model. RESULTS: Less than 25% of the snus users reported never having smoked. The overall probability of using flavoured snus was .45 (95% CI .44-.46), highest among daily (.51, 95% CI .47-.54) and former daily smokers (.50, 95% CI .48-.52), and lowest among never (.41, 95% CI .39-.43) and occasional smokers without any prior history of daily smoking (.41, 95% CI .38-.44). Use of flavoured products was higher among female snus users (p = .67, 95% CI .65-.69) compared to males (p = .35, 95% CI .34-.36), highest among the youngest age group, 15-24 years (p = .58, 95% CI .56-.60) and decreased with increasing age. CONCLUSION: Regulation that would ban or limit flavoured snus use may affect smokers-an at risk population-more than never smokers. The health authorities should be mindful of the real-world complexity governing potential harms and benefits of flavour restrictions on snus. A further assessment of flavour limitations should acknowledge that flavoured snus products also function as alternatives to cigarettes.

The role of education for current, former and never-smoking among non-western immigrants in Norway. Does the pattern fit the model of the cigarette epidemic?

OBJECTIVES: The aim was (1) to investigate the association between education and smoking status (current, former and never-smoking) among non-western immigrants in Norway and (2) examine if these associations fit the pattern predicted by the model of the cigarette epidemic. DESIGN: Data came from the Oslo Health Study and the Oslo Immigrant Health study (2000-2002). The first included all Oslo citizens from seven selected birth cohorts. The second included all Oslo citizens born in Turkey, Iran, Pakistan, Vietnam and Sri Lanka. 14,768 respondents answered questions on smoking, education and relevant background variables (over-all response rate 43.3%). Two gender specific multinomial logistic regression models with smoking status [current, former or never-smoker (reference)] as dependent variable were computed and predicted probabilities of smoking status among groups with different levels of education were calculated. RESULTS: Smoking prevalence among men ranged from 19% among Sri Lankans to 56% among Turks. Compared to the smoking prevalence among Norwegian men (27%), smoking was widespread among Iranians (42%) and Vietnamese (36%). Higher education was associated with lower probability of current smoking among all male immigrant groups except Sri Lankans. Never having smoked was positively associated with education among Pakistani and Norwegian men. Among women, <5% smoked among Pakistanis, Vietnamese and Sri Lankans. Smoking prevalence among Turkish (28%) and Iranian (23%) women were comparable to Norwegian women (30%). The probability of smoking among Turkish and Iranian women with secondary education was higher than for other levels of education. The probability of being a never-smoker was high among Turkish and Iranian women with primary education. CONCLUSIONS: High smoking prevalence among Turkish and Iranian men highlights the importance of addressing smoking behaviour in subgroups of the general population. Smoking was almost non-existent among Pakistani, Vietnamese and Sri Lankan women and indicates strong persistent social norms against smoking.

The impact of the COVID-19 epidemic on where tobacco users purchased cigarettes and snus in different Norwegian regions.

Aims: With the spread of COVID-19, the Norwegian government introduced restrictions on cross-border travel starting March 2020. Purchase of tobacco when travelling, especially from Sweden and duty-free shops, has comprised a substantial part of Norwegian tobacco consumption for many years. We investigated whether COVID-19-related travel restrictions and recommendations led to changes in tobacco purchases from Norway, Sweden, duty-free, other countries, possible illicit sources and web shops. Design: Based on a survey conducted by Ipsos, we examined: (i) the prevalence of smoking and snus use and where smokers and snus users reported having purchased tobacco consumed during the last 24 hours from 2015 to 2019, by county; and (ii) the probabilities of having purchased tobacco from different sources in the period before and after COVID-19-related travel restrictions and recommendations. Results: The proportion of smokers varied from 12% to 19% and the proportion of snus users varied from 12% to 21% across counties. Cigarettes bought in Norway comprised from 27% to 79% of the previous day's consumption, depending on the respondent's county of residence. For snus, the percentages ranged from 20% to 70%. The probability of buying tobacco in Norway increased by around 30 percentage points during the period of COVID-19-related travel restrictions and recommendations, compared with previous years. The increase was greatest in border regions and was accompanied by fewer purchases in Swedish and duty-free shops. Conclusion: The increased share of tobacco purchases from shops in Norway means that, for many tobacco users, buying tobacco become more expensive and that taxes on tobacco to a greater extent were paid in Norway. However, whether these extraordinary circumstances will affect future cigarette and snus use, and place of purchase of tobacco products, remains to be seen.

Beliefs about harms of cigarette smoking among Norwegian adults born from 1899 to 1969. Do variations across education, smoking status and sex mirror the decline in smoking?

BACKGROUND AND AIM: Smoking is one of the most important causes of socioeconomic disparities in morbidity and mortality. The aim of this study was to examine if beliefs about harms of smoking differed across gender, smoking status and education among Norwegian adults born between 1899 and 1969. METHODS: Using data from a nationally representative survey of smoking habits and a multinomial logit/negative binomial two-stage hurdle model design, we examined (first hurdle) the associations between birth cohort, gender, education and smoking status and four beliefs about cigarette smoking: i) smoking is not harmful, ii) do not know if smoking is harmful, iii) any number of cigarettes per day (CPD) is harmful and iv) smoking more than a given nonzero number of CPD is harmful, and (second hurdle) the predicted number of CPD that could be smoked without causing harm (from outcome iv). RESULTS: The probability of believing that smoking was not harmful was close to zero, regardless of birth cohort, sex, education and smoking status. The probability of not knowing if smoking was harmful decreased from around 0.7 to almost zero across cohorts. The probability of believing that smoking more than zero CPD was harmful increased from less than 0.1 to around 0.7, while the probability of believing that there is some safe level of smoking increased with cohorts born from 1900 to 1930 before declining. Respondents with primary/secondary education consistently believed smoking to be less harmful compared to respondents with tertiary education, but cohort trajectories were similar. DISCUSSION: The similar birth cohort trajectories in beliefs about the harms of smoking do not support the idea that Norwegian adults with lower education has had qualitatively different beliefs about the harmfulness of smoking compared to those with higher education. The persistent and large socioeconomic gradient is likely a result of other factors.

A conceptual framework for assessing the public health effects from snus and novel non-combustible nicotine products.

Objective: The tobacco industry plans to base their future earnings on the production of non-combustible nicotine products. These might replace or come in addition to the more harmful cigarettes that historically have dominated the nicotine market in the Nordic countries. The authorities in each country must decide whether the products should have market access and, in that case, how strictly they should be regulated. Our aim is to present a framework that can assist the health authorities to make a regulation where benefits will outweigh the harms. Method: In a public health perspective, health gains from substitution must be weighed against the health loss from additional use. The main elements of the weighing will be based on the information about the absolute risk of the products, their relative risk compared to conventional cigarettes and how the users are composed according to smoking status. We apply the framework on snus as used in Norway - a product with an established usage pattern and epidemiologically assessed health risks. Results: The framework consists of (i) a comprehensive set of specific user patterns that may result in health deterioration and user patterns that may result in health benefits, (ii) an estimation of the number of people with health-augmenting and health-impairing user patterns, respectively, and (iii) an estimation of the degree of health deterioration or health benefit that will affect the persons with the different user patterns. Conclusion: The net effect on public health will appear as an overall result of the number of people with positive and negative user patterns, respectively, in combination with the magnitude of the change in health status these people will experience. The use of an explicit framework highlights how a political decision may affect nicotine use and health-related outcomes. The framework breaks open a large and complex question into smaller pieces and requires the authorities to expose and explain the kind of evidence and reasoning behind regulations of novel nicotine products.

Relative Risk Perceptions between Snus and Cigarettes in a Snus-Prevalent Society-An Observational Study over a 16 Year Period.

Background: Most studies on perceived risks of smokeless tobacco products (SLT) have been conducted in the U.S., and the vast majority conclude that perceptions of the relative harmfulness of SLT versus cigarettes in the population are inconsistent with epidemiologically-based risk estimates, and typically conflated to that of cigarettes. We tested whether such inaccuracies also existed in Norway, where SLT-products are less toxic (Swedish snus) and SLT use is more prevalent than in the U.S. Methods: Over a 16 years period (2003⁻2018), 13,381 respondents (aged 16⁻79 years) answered questions about risk perceptions in Statistics Norway's nationally representative survey of tobacco behavior. We applied an indirect measure of comparative harm where risk beliefs for eight nicotine products were assessed independently of other products and then compared the answers. The wording of the question was: "We will now mention a variety of nicotine products and ask you how harmful you think daily use of these are. Use a scale from 1 to 7, where 1 is slightly harmful and 7 is very harmful". Mean scores with 95% confidence intervals were calculated. Results: The overall risk score for cigarettes was 6.48. The risk score for snus was 5.14⁻79.3% of the risk score of cigarettes. The relative risk scores for e-cigarettes (3.78) and NRT products (3.39) was 58.4% and 52.3% when compared to cigarettes. Perceptions of risk were stable over time. A strong association was observed between perceived risk of snus and having used snus in attempts to quit smoking. Conclusion: Perceptions of relative risk between snus and cigarettes is inconsistent with estimates from medical expert committees, which assess the overall health risk from use of Swedish snus to be minor when compared to the risk from smoking. Like the situation in the US, incorrect beliefs about SLT risks seem to be prevalent also in the snus-prevalent Norwegian setting. Accurate information on differential harms needs to be communicated. Future research should try to identify reasons why health authorities in the US and Scandinavia allow these well-documented misconceptions to persist.

Do never smokers make up an increasing share of snus users as cigarette smoking declines? Changes in smoking status among male snus users in Norway 2003-15.

AIMS: To examine how the relative size of six groups of male ever snus users (current and former users of snus who were current, former or never cigarette smokers) varied over time in Norway, and how these groups differ with regard to important measures of tobacco behaviour. DESIGN: Repeated cross-sectional nationally representative surveys of tobacco use. The association between survey year and the six categories of ever snus use was examined using cross-tabulation and multinomial logistic regression. Differences in tobacco behaviour across snus use categories were examined using logistic and ordinary least squares (OLS) regression. SETTING: Norway, 2003-15. PARTICIPANTS: A total of 2067 males aged 15-79 years. MEASUREMENTS: The categories of ever snus use represented all six combinations of cigarette smoking (current, former or never) among current and former users of snus. The variables measuring tobacco behaviour were: order of product uptake (snus or cigarettes first), mean cigarette consumption, reduction from daily to occasional smoking, intention to quit cigarettes, future smoking identity and use of snus in latest quit attempt. FINDINGS: During the period 2003-15, the relative share of current snus users who had never smoked, and current snus users who were former smokers, increased. The share of dual users, and smokers who were former snus users, decreased. Among men who reported life-time experience with both products, a large majority had initiated their tobacco use with cigarettes. The average number of cigarettes smoked weekly was lower among dual users compared with current smokers who were former snus users or had never used snus. CONCLUSIONS: During the period 2003-15 in Norway, which has a mature snus market, even though smoking has declined and the relative size of the category of never-smokers among male users of snus has increased, the majority of snus users are still former or current smokers.